Maham Hayat, MD1, Hassaan Zia, MD1, Muhammad Hashim Hayat, MBBS2, Ahmed Bolkhir, MD1
1University of Oklahoma Health Sciences Center, Oklahoma City, OK; 2University of Health Sciences, Oklahoma City, OK
Introduction: Arteriobiliary fistula is an uncommon complication manifesting as hemobilia or an upper gastrointestinal (GI) bleed. Etiologies include intra-hepatic artery chemo-embolization, trauma or previous invasive biliary instrumentation. We describe a case report of using two fully covered metal biliary stents for closure of an acquired arteriobiliary fistula.
Case Description/Methods: 20-year old male with history of neuroblastoma s/p resection and chemoradiation underwent placement of percutaneous transhepatic biliary drain (PTBD) for common bile duct (CBD) strictures. He was admitted to the hospital with acute blood loss anemia, transaminitis and sanguineous output from the biliary drain. Upper endoscopy revealed one clean based gastric ulcer which was injected with epinephrine. Patient was scheduled to undergo replacement of external/internal biliary drain. Intraoperative cholangiogram revealed extensive thrombus within central biliary ducts. It also demonstrated a fistulous connection between the common hepatic duct and the right hepatic artery. Angiogram showed replaced right hepatic artery, originating from superior mesenteric artery with occluded 4 cm proximal end, distal reconstitution was seen via fine collaterals; which made endovascular repair impossible (FIG A left). As a temporizing measure, a COOK 16Fr x 40cm biliary drain was replaced and advanced beyond the arterial-biliary fistulous connection, serving as a tamponade (FIG A right). Over the subsequent days, patient continued to have intermittent sanguineous biliary output. After surgical options were ruled out, two GORE VIABAHN 11mm x 29 mm balloon expandable fully covered metal stents were deployed within the common bile duct to exclude the biliary-right hepatic artery fistula (FIG B left, right). A similar sized biliary drain was replaced subsequently (FIG C). Hemobilia resolved and hemoglobin remained stable. Patient was discharged successfully to a center of excellence for multivisceral transplant.
Discussion: The management of hematobilia often includes an initial cholangiogram, if an arterial source is identified, hepatic artery embolization is the treatment of choice. This unique case demonstrates the utility of an endobiliary prosthesis for exclusion of arteriobiliary fistula where endovascular repair was not an option. The shortest possible endoprosthesis should be used to avoid obliteration of other large vessels or bile duct branches. Complications include bacteremia and liver infarction adjacent to stent-grafts.
Citation: Maham Hayat, MD; Hassaan Zia, MD; Muhammad Hashim Hayat, MBBS; Ahmed Bolkhir, MD. P0057 - ARTERIOBILIARY FISTULA REPAIR WITH BILIARY ENDOPROSTHESIS: WHEN TRANS ARTERIAL EMBOLIZATION IS NOT AN OPTION. Program No. P0057. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.